Provider Demographics
NPI:1093379307
Name:GELLER, JONATHAN DAVID (MSW)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:DAVID
Last Name:GELLER
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 KINGS HIGHWAY NORTH
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880
Mailing Address - Country:US
Mailing Address - Phone:203-221-0333
Mailing Address - Fax:
Practice Address - Street 1:166 KINGS HIGHWAY NORTH
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880
Practice Address - Country:US
Practice Address - Phone:203-221-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001388LCSW104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker